Remote Delivery of Allied Health Therapies in Parkinson's Disease

Remote delivery of allied health therapies has long been possible, but adoption has been limited in some disciplines until relatively recently. The COVID-19 pandemic drove dramatic increases in use of remote delivery within allied health. This review summarizes the latest evidence on remotely-delivered physical therapy, occupational therapy, and speech therapy and discusses associated challenges and opportunities.

Natural Walking Intensity in Persons With Parkinson Disease

BACKGROUND AND PURPOSE

Few persons with Parkinson disease (PD) appear to engage in moderate-intensity walking associated with disease-modifying health benefits. How much time is spent walking at lower, yet still potentially beneficial, intensities is poorly understood. The purpose of this exploratory, observational study was to describe natural walking intensity in ambulatory persons with PD.

METHODS

Accelerometer-derived real-world walking data were collected for more than 7 days at baseline from 82 participants enrolled in a PD clinical trial. Walking intensity was defined according to the number of steps in each active minute (1-19, 20-39, 40-59, 60-79, 80-99, or ≥100 steps). Daily minutes of walking and duration of the longest sustained walking bout were calculated at each intensity. Number of sustained 10 to 19, 20 to 29, and 30-minute bouts and greater at any intensity also were calculated. Values were analyzed in the context of physical activity guidelines.

RESULTS

Most daily walking occurred at lower intensities (157.3 ± 58.1 min of 1-19 steps; 81.3 ± 32.6 min of 20-39 steps; 38.2 ± 21.3 min of 40-59 steps; 15.1 ± 11.5 min of 60-79 steps; 7.4 ± 7.0 min of 80-99 steps; 7.3 ± 9.6 min of ≥100 steps). The longest daily sustained walking bout occurred at the lowest intensity level (15.9 ± 5.2 min of 1-19 steps). Few bouts lasting 20 minutes and greater occurred at any intensity.

DISCUSSION AND CONCLUSIONS

Despite relatively high daily step counts, participants tended to walk at remarkably low intensity, in bouts of generally short duration, with relatively few instances of sustained walking. The findings reinforced the need for health promotion interventions designed specifically to increase walking intensity.Video Abstract available for more insight from authors (see the Video, Supplemental Digital Content 1 available at: http://links.lww.com/JNPT/A426).

Prospective associations between accelerometry-derived physical activity and sedentary behaviors and mortality among cancer survivors

BACKGROUND

Survival benefits of self-reported recreational physical activity (PA) during cancer survivorship are well-documented in common cancer types, yet there are limited data on the associations between accelerometer-derived PA of all domains, sedentary behavior, and mortality in large, diverse cohorts of cancer survivors.

METHODS

Participants included adults who reported a cancer diagnosis in the National Health and Nutrition Examination Survey and wore an accelerometer for up to 7 days in 2003-2006. Participants were followed for subsequent mortality through 2015. We examined the association of light PA, moderate to vigorous PA, total PA, and sedentary behavior, with all-cause mortality. Cox proportional hazards models estimated hazard ratios (HRs) and 95% confidence intervals (CIs), adjusting for demographics and health indicators.

RESULTS

A total of 480 participants (mean age of 68.8 years [SD = 12.4] at the time of National Health and Nutrition Examination Survey assessment) reported a history of cancer. A total of 215 deaths occurred over the follow-up period. For every 1-h/d increase in light PA and moderate to vigorous PA (MVPA), cancer survivors had 49% (HR = 0.51, 95% CI = 0.34 to 0.76) and 37% (HR = 0.63 , 95% CI = 0.40 to 0.99) lower hazards of all-cause mortality, respectively. Total PA demonstrated similar associations with statistically significantly lower hazards of death for each additional hour per day (HR = 0.68, 95% CI = 0.54 to 0.85), as did every metabolic equivalents of task-hour per day increase in total PA estimations of energy expenditure (HR = 0.88, 95% CI = 0.82 to 0.95). Conversely, more sedentary time (1 h/d) was not associated with statistically significantly higher hazards (HR = 1.08, 95% CI = 0.94 to 1.23).

CONCLUSIONS

These findings reinforce the current recommendations for cancer survivors to be physically active and underscore the continued need for widespread PA promotion for long-term survival in older cancer survivors.

Does clinically measured walking capacity contribute to real-world walking performance in Parkinson's disease?

OBJECTIVE

The study examined how clinically measured walking capacity contributes to real-world walking performance in persons with Parkinson's disease (PD).

METHODS

Cross-sectional baseline data (n = 82) from a PD clinical trial were analyzed. The 6-Minute Walk Test (6MWT) and 10-Meter Walk Test (10MWT) were used to generate capacity metrics of walking endurance and fast gait speed, respectively. An activity monitor worn for seven days was used to generate performance metrics of mean daily steps and weekly moderate intensity walking minutes. Univariate linear regression analyses were used to examine associations between each capacity and performance measure in the full sample and less and more active subgroups.

RESULTS

Walking capacity significantly contributed to daily steps in the full sample (endurance: R2=.13, p < .001; fast gait speed: R2=.07, p = .017) and in the less active subgroup (endurance: R2 =.09, p = .045). Similarly, walking capacity significantly contributed to weekly moderate intensity minutes in the full sample (endurance: R2=.13, p < .001; fast gait speed: R2=.09, p = .007) and less active subgroup (endurance: R2 = .25, p < .001; fast gait speed: R2 =.21, p = .007). Walking capacity did not significantly contribute to daily steps or moderate intensity minutes in the more active subgroup.

CONCLUSIONS

Walking capacity contributed to, but explained a relatively small portion of the variance in, real-world walking performance. The contribution was somewhat greater in less active individuals. The study adds support to the idea that clinically measured walking capacity may have limited benefit for understanding real-world walking performance in PD. Factors beyond walking capacity may better account for actual walking behavior.

Musculoskeletal pain in Parkinson's disease: a narrative review

The prevalence of musculoskeletal (MSK) pain in people with Parkinson's disease (PD) is higher than that of age-matched controls. In this review, we outline what is known about MSK pain in PD, focusing on the neck, shoulder, knee, hip and low back. We also compare what is known about MSK pain in PD to what is known in older adults without PD. Finally, we outline areas of for future research related to MSK pain in people with PD.

Are Mobile Persons With Parkinson Disease Necessarily More Active?

BACKGROUND AND PURPOSE

Walking activity in persons with Parkinson disease (PD) is important for preventing functional decline. The contribution of walking activity to home and community mobility in PD is poorly understood.

METHODS

Cross-sectional baseline data (N = 69) were analyzed from a randomized controlled PD trial. The Life-Space Assessment (LSA) quantified the extent, frequency, and independence across 5 expanding levels of home and community mobility, producing individual subscores and a total score. Two additional summed scores were used to represent mobility within (Levels 1-3) and beyond (Levels 4-5) neighborhood limits. An accelerometer measured walking activity for 7 days. Regression and correlation analyses evaluated relationships between daily steps and mobility scores. Mann-Whitney U tests secondarily compared differences in mobility scores between the active and sedentary groups.

RESULTS

Walking activity contributed significantly to the summed Level 1-3 score (β = 0.001, P = 0.004) but not to the summed Level 4-5 (β = 0.001, P = 0.33) or total (β = 0.002, P = 0.07) scores. Walking activity was significantly related to Level 1 (ρ = 0.336, P = 0.005), Level 2 (ρ = 0.307, P = 0.010), and Level 3 (ρ = 0.314, P = 0.009) subscores. Only the summed Level 1-3 score (P = 0.030) was significantly different between the active and sedentary groups.

DISCUSSION AND CONCLUSIONS

Persons with PD who demonstrated greater mobility beyond the neighborhood were not necessarily more active; walking activity contributed more so to home and neighborhood mobility. Compared with LSA total score, the Level 1-3 summed score may be a more useful participation-level measure for assessing the impact of changes in walking activity.Video Abstract available for more insights from the authors (see the Video, Supplemental Digital Content 1 available at: http://links.lww.com/JNPT/A349).

The Role of Mental Imagery in Parkinson's Disease Rehabilitation

Parkinson’s disease (PD) is a disabling neurodegenerative disease whose manifestations span motor, sensorimotor, and sensory domains. While current therapies for PD include pharmacological, invasive, and physical interventions, there is a constant need for developing additional approaches for optimizing rehabilitation gains. Mental imagery is an emerging field in neurorehabilitation and has the potential to serve as an adjunct therapy to enhance patient function. Yet, the literature on this topic is sparse. The current paper reviews the motor, sensorimotor, and sensory domains impacted by PD using gait, balance, and pain as examples, respectively. Then, mental imagery and its potential for PD motor and non-motor rehabilitation is discussed, with an emphasis on its suitability for addressing gait, balance, and pain deficits in people with PD. Lastly, future research directions are suggested.

Design of the WHIP-PD study: a phase II, twelve-month, dual-site, randomized controlled trial evaluating the effects of a cognitive-behavioral approach for promoting enhanced walking activity using mobile health technology in people with Parkinson-disease

Background

Parkinson disease (PD) is a debilitating and chronic neurodegenerative disease resulting in ambulation difficulties. Natural walking activity often declines early in disease progression despite the relative stability of motor impairments. In this study, we propose a paradigm shift with a “connected behavioral approach” that targets real-world walking using cognitive-behavioral training and mobile health (mHealth) technology.

Methods/design

The Walking and mHealth to Increase Participation in Parkinson Disease (WHIP-PD) study is a twelve-month, dual site, two-arm, randomized controlled trial recruiting 148 participants with early to mid-stage PD. Participants will be randomly assigned to connected behavioral or active control conditions. Both conditions will include a customized program of goal-oriented walking, walking-enhancing strengthening exercises, and eight in-person visits with a physical therapist. Participants in the connected behavioral condition also will (1) receive cognitive-behavioral training to promote self-efficacy for routine walking behavior and (2) use a mHealth software application to manage their program and communicate remotely with their physical therapist. Active control participants will receive no cognitive-behavioral training and manage their program on paper. Evaluations will occur at baseline, three-, six-, and twelve-months and include walking assessments, self-efficacy questionnaires, and seven days of activity monitoring. Primary outcomes will include the change between baseline and twelve months in overall amount of walking activity (mean number of steps per day) and amount of moderate intensity walking activity (mean number of minutes per day in which > 100 steps were accumulated). Secondary outcomes will include change in walking capacity as measured by the six-minute walk test and ten-meter walk test. We also will examine if self-efficacy mediates change in amount of walking activity and if change in amount of walking activity mediates change in walking capacity.

Discussion

We expect this study to show the connected behavioral approach will be more effective than the active control condition in increasing the amount and intensity of real-world walking activity and improving walking capacity. Determining effective physical activity interventions for persons with PD is important for preserving mobility and essential for maintaining quality of life. Clinical trials registration NCT03517371, May 7, 2018.

Trial registration

ClinicalTrials.gov: NCT03517371. Date of registration: May 7, 2018. Protocol version: Original.

Low Back Pain--Related Disability in Parkinson Disease: Impact on Functional Mobility, Physical Activity, and Quality of Life

BACKGROUND

People with Parkinson disease (PD) frequently experience low back pain (LBP), yet the impact of LBP on functional mobility, physical activity, and quality of life (QOL) has not been described in PD.

OBJECTIVE

The objectives of this study were to describe body positions and functional activities associated with LBP and to determine the relationships between LBP-related disability and PD motor sign severity, physical activity level, and QOL.

DESIGN

The study was a cross-sectional study.

METHODS

Thirty participants with idiopathic PD (mean age = 64.6 years [SD = 10.3]; 15 women) completed the Revised Oswestry Disability Questionnaire (RODQ), a measure of LBP-related disability. PD motor symptom severity was measured using the Movement Disorder Society-Unified Parkinson Disease Rating Scale Part III (MDS-UPRDS III). The Physical Activity Scale for the Elderly (PASE) was used to measure self-reported physical activity. The Parkinson Disease Questionnaire-39 (PDQ-39) was used to measure QOL. Descriptive statistics were used to characterize LBP intensity and LBP-related disability. Spearman correlations were used to determine relationships between the RODQ and the MDS-UPDRS III, PASE, and PDQ-39.

RESULTS

LBP was reported to be of at least moderate intensity by 63.3% of participants. LBP most frequently impaired standing, sleeping, lifting, and walking. The RODQ was significantly related to the MDS-UPDRS III (r = 0.38), PASE (r = -0.37), PDQ-39 summary index (r = 0.55), PDQ-39 mobility subdomain (r = 0.54), and PDQ-39 bodily pain subdomain (r = 0.44).

LIMITATIONS

Limitations included a small sample of people with mild to moderate PD severity, the fact that RODQ is a less frequently used measure of LBP-related disability, and the lack of a non-PD control group.

CONCLUSIONS

LBP affected walking, sleeping, standing, and lifting in this small sample of people with mild to moderate PD. Greater LBP-related disability was associated with greater motor sign severity, lower physical activity level, and lower QOL in people with PD.

Assessing the Translation of Research and Innovation into Dental Practice

INTRODUCTION

Over the past 100 y, there have been an unprecedented number of innovations that have improved oral health and functioning. Variations in lag times between discovery and clinical adoption are related to dentist education, the clinical availability of technology, and the perceived value of an innovation.

OBJECTIVES

The purposes of this cross-sectional study were 1) catalogue research discoveries and innovations over the past 30 y and 2) from that list identify those which practicing dentists believe have maximally affected patient care.

METHODS

Thirty International Association for Dental Research leaders identified innovations over the past 30 y that have significantly affected dental care. The 30 most cited innovations were included in a questionnaire that was sent to a random sample of US dentists who graduated dental school during or before 1995 (before the recency of identified discoveries) and devoted ≥50% of their time to patient care. Eighty-two percent of respondents identified as general dentists and 18% as specialists. Respondents were asked to identify 5 to 7 items whose loss would have the most adverse effects on patient care.

RESULTS

The most cited advances were adhesive dental materials (74.5%), dental implants (71.9%), direct bonding systems (71.2%), dental loupes (54.7%), universal precautions for infection control (48.6%), and digital imaging (46.0%). There were differences in the ranking of responses between generalists and specialists. For the oral surgeons and periodontists (OMSPER, n = 51), top choices were dental implants (82%), cone beam computed tomography (CBCT) imaging (74%), regenerative dentistry and tissue engineering (68%), universal precautions (58%), digital imaging (56%), and dental loupes (48%).

CONCLUSIONS

There was agreement among generalists and specialists about the importance of dental implants, digital imaging, use of dental loupes, and universal precautions in improving patient care. However, generalists also cited the importance of adhesive dental materials and bonding, and OMSPER cited CBCT and biological-based tissue restoration as major advances.

KNOWLEDGE TRANSFER STATEMENT

Many advances in dental patient care capitalize on innovations and technologies that have emerged after dentists graduate from dental school. Adoption of new technologies is influenced by information acquired from professional journals, continuing education, industry marketing activities, and interactions with colleagues. The results of this study suggest that innovations that are directly related to clinical procedures were rated most impactful. Future research should consider cost-effectiveness and patient perceptions on the impact of innovations and technologies.

Freezing of Gait Boot Camp: feasibility, safety and preliminary efficacy of a community-based group intervention

AIM

In this pilot study, we evaluated the feasibility, safety and preliminary efficacy of a 6-week, community-based group intervention designed to reduce freezing of gait (FOG) for people with Parkinson's disease (PD).

METHODS

Seven people with PD completed 'FOG Boot Camp' provided by the St. Louis Chapter of the American Parkinson Disease Association. We recorded attendance, participant's acceptance of the intervention and adverse events during classes. Pre and post-tests included measures of freezing, balance, motor severity, quality-of-life and gait speed.

RESULTS

No falls or injuries occurred and attendance was high. Participants had favorable feedback and showed reduced freezing and improvements in balance and gait.

CONCLUSION

Preliminary data suggest the FOG boot camp was feasible, safe and effective.

Effects of exercise on gait and motor imagery in people with Parkinson disease and freezing of gait

INTRODUCTION

Exercise improves gait in Parkinson disease (PD), but whether exercise differentially affects people with PD with (freezers) and without freezing of gait (non-freezers) remains unclear. This study examines exercise's effects on gait performance, neural correlates related to these effects, and potential neural activation differences between freezers and non-freezers during motor imagery (MI) of gait.

METHODS

Thirty-seven participants from a larger exercise intervention completed behavioral assessments and functional magnetic resonance imaging (fMRI) scans before and after a 12-week exercise intervention. Gait performance was characterized using gait velocity and stride length, and a region of interest (ROI) fMRI analysis examined task-based blood oxygen-level dependent (BOLD) signal changes of the somatomotor network (SMN) during MI of forward (IMG-FWD) and backward (IMG-BWD) gait.

RESULTS

Velocity (F(1,34) = 55.04, p < 0.001) and stride length (F(1,34) = 77.58, p < 0.001) were significantly lower for backward versus forward walking in all participants. The ROI analysis showed freezers had lower BOLD signal compared to non-freezers in the cerebellum (F(1,32) = 7.01, p = 0.01), primary motor (left: F(1,32) = 7.09, p = 0.01; right: F(1,32) = 7.45, p = 0.01), and primary sensory (left: F(1,32) = 9.59, p = 0.004; right: F(1,32) = 8.18, p = 0.007) cortices during IMG-BWD only. The evidence suggests the exercise intervention did not affect gait or BOLD signal during MI.

CONCLUSION

While all participants had significantly slower and shorter backward velocity and stride length, respectively, the exercise intervention had no effect. Similarly, BOLD signal during MI did not change with exercise; however, freezers had significantly lower BOLD signal during IMG-BWD compared to non-freezers. This suggests potential decreased recruitment of the SMN during MI of gait in freezers.

Physical therapy and deep brain stimulation in Parkinson's Disease: protocol for a pilot randomized controlled trial

Background

Subthalamic nucleus deep brain stimulation (STN-DBS) reduces tremor, muscle stiffness, and bradykinesia in people with Parkinson’s Disease (PD). Walking speed, known to be reduced in PD, typically improves after surgery; however, other important aspects of gait may not improve. Furthermore, balance may worsen and falls may increase after STN-DBS. Thus, interventions to improve balance and gait could reduce morbidity and improve quality of life following STN-DBS. Physical therapy (PT) effectively improves balance and gait in people with PD, but studies on the effects of PT have not been extended to those treated with STN-DBS. As such, the efficacy, safety, and feasibility of PT in this population remain to be determined. The purpose of this pilot study is to address these unmet needs. We hypothesize that PT designed to target balance and gait impairment will be effective, safe, and feasible in this population.

Methods/design

Participants with PD treated with STN-DBS will be randomly assigned to either a PT or control group. Participants assigned to PT will complete an 8-week, twice-weekly PT program consisting of exercises designed to improve balance and gait. Control group participants will receive the current standard of care following STN-DBS, which does not include prescription of PT. The primary aim is to assess preliminary efficacy of PT on balance (Balance Evaluation Systems Test). A secondary aim is to assess efficacy of PT on gait (GAITRite instrumented walkway). Participants will be assessed OFF medication/OFF stimulation and ON medication/ON stimulation at baseline and at 8 and 12 weeks after baseline. Adverse events will be measured over the duration of the study, and adherence to PT will be measured to determine feasibility.

Discussion

To our knowledge, this will be the first study to explore the preliminary efficacy, safety, and feasibility of PT for individuals with PD with STN-DBS. If the study suggests potential efficacy, then this would justify larger trials to test effectiveness and safety of PT for those with PD with STN-DBS.

Trial registration

NCT03181282 (clinicaltrials.gov). Registered on 7 June 2017.

Electronic supplementary material

The online version of this article (10.1186/s40814-018-0243-2) contains supplementary material, which is available to authorized users.

Low to moderate relationships between gait and postural responses in Parkinson disease

OBJECTIVE

To evaluate the relationship between spatiotemporal parameters of forward and backward gait and quality of compensatory stepping responses in forward and backward directions in people with Parkinson's disease with and without freezing of gait.

DESIGN

Cross-sectional analysis.

SUBJECTS

A total of 111 individuals with mild to moderate Parkinson's disease.

METHODS

Forward and backward gait velocity and step length were evaluated using a GAITRite walkway. Forward and backward postural responses were evaluated using items from the Mini Balance Evaluation Systems Test and the Movement Disorders Society Unified Parkinson Disease Rating Scale motor subsection. Relationships between gait and postural responses were examined for the full sample and for sub-groups with and without freezing of gait.

RESULTS

There were significant (p < 0.05) low to moderate correlations between postural responses and gait overall. Correlations were similar in the freezer and non-freezer sub-groups. Freezers performed worse than non-freezers on all gait parameters and backward postural response items (p < 0.05).

CONCLUSION

Low to moderate relationships between gait and postural responses indicate the complexity of postural control and the potential involvement of different neural circuitry across these tasks. Better understanding of the relationships between gait and postural deficits in Parkinson's disease may inform the future development of targeted interventions to address these impairments.

Modeling, Detecting, and Tracking Freezing of Gait in Parkinson Disease Using Inertial Sensors

In this paper, we develop new methods to automatically detect the onset and duration of freezing of gait (FOG) in people with Parkinson disease (PD) in real time, using inertial sensors. We first build a physical model that describes the trembling motion during the FOG events. Then, we design a generalized likelihood ratio test framework to develop a two-stage detector for determining the zero-velocity and trembling events during gait. Thereafter, to filter out falsely detected FOG events, we develop a point-process filter that combines the output of the detectors with information about the speed of the foot, provided by a foot-mounted inertial navigation system. We computed the probability of FOG by using the point-process filter to determine the onset and duration of the FOG event. Finally, we validate the performance of the proposed system design using real data obtained from people with PD who performed a set of gait tasks. We compare our FOG detection results with an existing method that only uses accelerometer data. The results indicate that our method yields 81.03% accuracy in detecting FOG events and a threefold decrease in the false-alarm rate relative to the existing method.

Feasibility and preliminary efficacy of a telerehabilitation approach to group adapted tango instruction for people with Parkinson disease

People with Parkinson disease (PD) demonstrate improvements in motor function following group tango classes, but report long commutes as a barrier to participation. To increase access, we investigated a telerehabilitation approach to group tango instruction. Twenty-six people with mild-to-moderate PD were assigned based on commute distance to either the telerehabilitation group (Telerehab) or an in-person instruction group (In-person). Both groups followed the same twice-weekly, 12-week curriculum with the same instructor. Feasibility metrics were participant retention, attendance and adverse events. Outcomes assessed were balance, PD motor sign severity and gait. Participant retention was 85% in both groups. Attendance was 87% in the Telerehab group and 84% in the In-person group. No adverse events occurred. Balance and motor sign severity improved significantly over time ( p < 0.001) in both groups, with no significant group × time effects. Gait did not significantly change. Since a priori feasibility criteria were met or exceeded, and there were no notable outcome differences between the two instruction approaches, this pilot study suggests a telerehabilitation approach to group tango class for people with PD is feasible and may have similar outcomes to in-person instruction.

Investigation of factors impacting mobility and gait in Parkinson disease

Mobility and gait limitations are major issues for people with Parkinson disease (PD). Identification of factors that contribute to these impairments may inform treatment and intervention strategies. In this study we investigated factors that predict mobility and gait impairment in PD. Participants with mild to moderate PD and without dementia (n=114) were tested in one session 'off' medication. Mobility measures included the 6-Minute Walk test and Timed-Up-and-Go. Gait velocity was collected in four conditions: forward preferred speed, forward dual task, forward fast as possible and backward walking. The predictors analyzed were age, gender, disease severity, balance, balance confidence, fall history, self-reported physical activity, and executive function. Multiple regression models were used to assess the relationships between predictors and outcomes. The predictors, in different combinations for each outcome measure, explained 55.7% to 66.9% of variability for mobility and 39.5% to 52.8% for gait velocity. Balance was the most relevant factor (explaining up to 54.1% of variance in mobility and up to 45.6% in gait velocity). Balance confidence contributed to a lesser extent (2.0% to 8.2% of variance) in all models. Age explained a small percentage of variance in mobility and gait velocity (up to 2.9%). Executive function explained 3.0% of variance during forward walking only. The strong predictive relationships between balance deficits and mobility and gait impairment suggest targeting balance deficits may be particularly important for improving mobility and gait in people with PD, regardless of an individual's age, disease severity, fall history, or other demographic features.

Two-Year Trajectory of Fall Risk in People With Parkinson Disease: A Latent Class Analysis

OBJECTIVE

To examine fall risk trajectories occurring naturally in a sample of individuals with early to middle stage Parkinson disease (PD).

DESIGN

Latent class analysis, specifically growth mixture modeling (GMM), of longitudinal fall risk trajectories.

SETTING

Assessments were conducted at 1 of 4 universities.

PARTICIPANTS

Community-dwelling participants with PD of a longitudinal cohort study who attended at least 2 of 5 assessments over a 2-year follow-up period (N=230).

INTERVENTIONS

Not applicable.

MAIN OUTCOME MEASURES

Fall risk trajectory (low, medium, or high risk) and stability of fall risk trajectory (stable or fluctuating). Fall risk was determined at 6 monthly intervals using a simple clinical tool based on fall history, freezing of gait, and gait speed.

RESULTS

The GMM optimally grouped participants into 3 fall risk trajectories that closely mirrored baseline fall risk status (P=.001). The high fall risk trajectory was most common (42.6%) and included participants with longer and more severe disease and with higher postural instability and gait disability (PIGD) scores than the low and medium fall risk trajectories (P<.001). Fluctuating fall risk (posterior probability <0.8 of belonging to any trajectory) was found in only 22.6% of the sample, most commonly among individuals who were transitioning to PIGD predominance.

CONCLUSIONS

Regardless of their baseline characteristics, most participants had clear and stable fall risk trajectories over 2 years. Further investigation is required to determine whether interventions to improve gait and balance may improve fall risk trajectories in people with PD.

Differential Effects of Tango Versus Dance for PD in Parkinson Disease

Over half of the general population does not achieve recommended daily levels of physical activity, and activity levels in people with Parkinson disease (PD) are lower than in healthy older adults. Dance can serve as an adjunct to traditional treatments to improve gait, balance, and quality of life in people with PD. This study directly compares a tango dance intervention and a dance intervention based on the Dance for PD model, which integrates multiple dance styles. Eleven people with PD participated in a community-based mixed styles dance intervention called Dance for Parkinson's (D4PD). Participants in the D4PD group were matched to participants in an ongoing community-based exercise study who participated in tango dance. The groups received 12 weeks of intervention, attending 1-h group classes twice a week. Participants were evaluated off anti-PD medication before and after intervention. Measures of balance, repeated sit-to-stand performance and endurance (mini-balance evaluation systems test, four square step test, five times sit to stand, 6-min walk time) improved from pre to post similarly in both groups. Motor sign severity (movement disorders society unified Parkinson disease rating scale motor subsection) and functional mobility (timed up and go) improved in the tango group and worsened in the D4PD group. Gait velocity was not affected by either intervention. Direct comparisons of different interventions are -critical for developing optimal exercise interventions designed to specifically target motor impairments in PD. Tango dance interventions may preferentially improve mobility and motor signs in people with PD, compared to D4PD.

Detecting and predicting balance decline in Parkinson disease: a prospective cohort study

BACKGROUND

The natural progression of balance decline in individuals with Parkinson disease (PD) is not well understood.

OBJECTIVES

We aimed to: 1) compare the utility of three standardized clinical measures for detecting balance decline over 1-year, 2) identify components of balance susceptible to decline, and 3) identify factors useful for predicting future balance decline.

METHODS

Eighty people with PD (59% male; mean age 68.2 ± 9.3; Hoehn & Yahr range I-IV) completed Balance Evaluation Systems Test (BESTest), Mini-BESTest, and Berg Balance Scale (BBS) assessments. Baseline predictor variables included the MDS-UPDRS III sub-score, presence of freezing, 6-month fall history, age, gender, and physical activity. Balance and MDS-UPDRS III assessments were repeated at 6 (n = 51) and 12 months (n = 44).

RESULTS

BESTest and Mini-BESTest score declined over 6 and 12 months (P < 0.01). Postural responses, stability limits, and sensory orientation were most susceptible to decline. BBS score did not change (P > 0.01). MDS-UPDRS III score was unchanged over 6 months (P > 0.01), but declined over 12 months (P < 0.01). Change in BESTest score over 6 months was related to baseline MDS-UPDRS III, H&Y, freezing, and fall history (P < 0.05). Change in BESTest score over 12 months was related to baseline MDS-UPDRS III and freezing (P < 0.05). Change in Mini-BESTest over 12 months was related to baseline MDS-UPDRS III and age (P < 0.05).

CONCLUSIONS

The BESTest and Mini-BESTest were responsive to balance decline in individuals with PD and helped to identify decline in underlying balance components. Disease severity and freezing most consistently predicted balance decline in persons with PD.

Initiation and organization of events during the first cell cycle in mammals: applications in cloning

The technology of cloning involves transplanting a diploid nucleus into a mature oocyte cytoplast. The cytoplast is then activated to initiate the first cell cycle of development as a nuclear transplant embryo. Initiation and regulation of events during the first cell cycle are, therefore, critical for proper reprogramming of the donor nucleus and development as a cloned embryo. Activation is normally induced by the sperm and is mediated by a series of intracellular free calcium ([Ca(2+)](i)) oscillations that last for several hours. Although it is not known precisely how the sperm induces activation, current evidence favors the delivery, by the sperm, of a soluble protein factor that causes the production of IP3. IP3 acts to open a Ca(2+) channel in the endoplasmic reticulum and release Ca(2+) into the cytosol. A variety of methods have been used to duplicate or replace the sperm-induced [Ca(2+)](i) increase to cause activation in nuclear transplant embryos. It has been found that treatments that cause a single transient [Ca(2+)](i) activate some oocytes with the level of activation increasing as the oocyte ages. Attempts have been made to extend the period of time over which [Ca(2+)](i) oscillations occur. This has been successful in increasing activation rates of less mature oocytes but the techniques are still cumbersome. An alternative method, that has been very successful, is the combination of a treatment that elevates [Ca(2+)](i) and a treatment that maintains low levels of maturation promoting factor for several hours after the initial [Ca(2+)](i) elevation. The sperm also contributes the centrosome that organizes microtubules during the first cell cycle. One current hypothesis for regulation of sperm centrosomal activity consists of a dephosphorylation of sperm connecting piece proteins following sperm entry into the oocyte and activation of the oocyte. Dephosphorylation of these proteins results in the disassembly of the connecting piece and assembly of a functional centrosome. In nuclear transfer, centrosomal components are contributed by the donor cell. If the cell is fused to the cytoplast before centriole replication then a single aster forms. If the cell is fused after centriole replication then two asters form. In either case and even in parthenogenetic oocytes, which do not have centrioles, the first cell cycle progresses to metaphase. However, progress is slow and some defects are observed in the assembly of chromosomes into a metaphase plate.

Balance differences in people with Parkinson disease with and without freezing of gait

BACKGROUND

Freezing of gait (FOG) is a relatively common and remarkably disabling impairment associated with Parkinson disease (PD). Laboratory-based measures indicate that individuals with FOG (PD+FOG) have greater balance deficits than those without FOG (PD-FOG). Whether such differences also can be detected using clinical balance tests has not been investigated. We sought to determine if balance and specific aspects of balance, measured using Balance Evaluation Systems Test (BESTest), differs between PD+FOG and PD-FOG. Furthermore, we aimed to determine if time-efficient clinical balance measures (i.e. Mini-BESTest, Berg Balance Scale (BBS)) could detect balance differences between PD+FOG and PD-FOG.

METHODS

Balance of 78 individuals with PD, grouped as either PD+FOG (n=32) or PD-FOG (n=46), was measured using the BESTest, Mini-BESTest, and BBS. Between-groups comparisons were conducted for these measures and for the six sections of the BESTest using analysis of covariance. A PD composite score was used as a covariate.

RESULTS

Controlling for motor sign severity, PD duration, and age, PD+FOG had worse balance than PD-FOG when measured using the BESTest (p=0.008, F=7.35) and Mini-BESTest (p=0.002, F=10.37), but not the BBS (p=0.27, F=1.26). BESTest section differences were noted between PD+FOG and PD-FOG for reactive postural responses (p<0.001, F=14.42) and stability in gait (p=0.003, F=9.18).

CONCLUSIONS

The BESTest and Mini-BESTest, which specifically assessed reactive postural responses and stability in gait, were more likely than the BBS to detect differences in balance between PD+FOG and PD-FOG. Because it is more time efficient to administer, the Mini-BESTest may be the preferred tool for assessing balance deficits associated with FOG.

Impacts of dance on non-motor symptoms, participation, and quality of life in Parkinson disease and healthy older adults

Evidence indicates exercise is beneficial for motor and non-motor function in older adults and people with chronic diseases including Parkinson disease (PD). Dance may be a relevant form of exercise in PD and older adults due to social factors and accessibility. People with PD experience motor and non-motor symptoms, but treatments, interventions, and assessments often focus more on motor symptoms. Similar non-motor symptoms also occur in older adults. While it is well-known that dance may improve motor outcomes, it is less clear how dance affects non-motor symptoms. This review aims to describe the effects of dance interventions on non-motor symptoms in older adults and PD, highlights limitations of the literature, and identifies opportunities for future research. Overall, intervention parameters, study designs, and outcome measures differ widely, limiting comparisons across studies. Results are mixed in both populations, but evidence supports the potential for dance to improve mood, cognition, and quality of life in PD and healthy older adults. Participation and non-motor symptoms like sleep disturbances, pain, and fatigue have not been measured in older adults. Additional well-designed studies comparing dance and exercise interventions are needed to clarify the effects of dance on non-motor function and establish recommendations for these populations.

External validation of a simple clinical tool used to predict falls in people with Parkinson disease

BACKGROUND

Assessment of fall risk in an individual with Parkinson disease (PD) is a critical yet often time consuming component of patient care. Recently a simple clinical prediction tool based only on fall history in the previous year, freezing of gait in the past month, and gait velocity <1.1 m/s was developed and accurately predicted future falls in a sample of individuals with PD.

METHODS

We sought to externally validate the utility of the tool by administering it to a different cohort of 171 individuals with PD. Falls were monitored prospectively for 6 months following predictor assessment.

RESULTS

The tool accurately discriminated future fallers from non-fallers (area under the curve [AUC] = 0.83; 95% CI 0.76-0.89), comparable to the developmental study.

CONCLUSION

The results validated the utility of the tool for allowing clinicians to quickly and accurately identify an individual's risk of an impending fall.

A comparison of dance interventions in people with Parkinson disease and older adults

It is important for our aging population to remain active, particularly those with chronic diseases, like Parkinson disease (PD), which limit mobility. Recent studies in older adults and people with PD suggest dance interventions provide various motor benefits. The literature for dance in PD is growing, but many knowledge gaps remain, relative to what is known in older adults. The purpose of this review is to: (1) detail results of dance intervention studies in older adults and in PD, (2) describe limitations of dance research in these populations, and (3) identify directions for future study. Generally, a wide variety of dance styles have been investigated in older adults, while a more limited subset has been evaluated in PD. Measures vary widely across studies and a lack of standardized outcomes measures hinders cross-studies comparisons. Compared to the dance literature in older adults, there is a notable absence of evidence in the PD literature in outcome domains related to cardiovascular health, muscle strength, body composition, flexibility, and proprioception. As a whole, the dance literature supports substantial and wide-ranging benefits in both populations, but additional effort should be dedicated to well-designed comparative studies using standardized outcome measures to identify optimal treatment programs.

Comparing interventions and exploring neural mechanisms of exercise in Parkinson disease: a study protocol for a randomized controlled trial

BACKGROUND

Effective treatment of locomotor dysfunction in Parkinson disease (PD) is essential, as gait difficulty is an early and major contributor to disability. Exercise is recommended as an adjunct to traditional treatments for improving gait, balance, and quality of life. Among the exercise approaches known to improve walking, tango and treadmill training have recently emerged as two promising therapies for improving gait, disease severity and quality of life, yet these two interventions have not been directly compared to each other. Prior studies have been helpful in identifying interventions effective in improving gait function, but have done little to elucidate the neural mechanisms underlying functional improvements. The primary objective of the proposed work is to compare the effects of three community-based exercise programs, tango, treadmill training and stretching, on locomotor function in individuals with PD. In addition, we aim to determine whether and how these interventions alter functional connectivity of locomotor control networks in the brain.

METHODS/DESIGN

One hundred and twenty right-handed individuals with idiopathic PD who are at least 30 years of age will be assigned in successive waves to one of three community-based exercise groups: tango dancing, treadmill training or stretching (control). Each group will receive three months of exercise training with twice weekly one-hour group classes. Each participant will be evaluated at three time points: pre-intervention (baseline), post-intervention (3 months), and follow-up (6 months). All evaluations will include assessment of gait, balance, disease severity, and quality of life. Baseline and post-intervention evaluations will also include task-based functional magnetic resonance imaging (fMRI) and resting state functional connectivity MRI. All MRI and behavioral measures will be conducted with participants OFF anti-Parkinson medication, with behavioral measures also assessed ON medication.

DISCUSSION

This study will provide important insights regarding the effects of different modes of exercise on locomotor function in PD. The protocol is innovative because it: 1) uses group exercise approaches for all conditions including treadmill training, 2) directly compares tango to treadmill training and stretching, 3) tests participants OFF medication, and 4) utilizes two distinct neuroimaging approaches to explore mechanisms of the effects of exercise on the brain.

TRIAL REGISTRATION

ClinicalTrials.gov NCT01768832 .

Are the effects of community-based dance on Parkinson disease severity, balance, and functional mobility reduced with time? A 2-year prospective pilot study

OBJECTIVE

To determine the effects of participation in a 2-year community-based dance class on disease severity and functional mobility in people with Parkinson disease (PD).

DESIGN

Randomized controlled trial.

SETTINGS/LOCATION

Dance classes took place in a community-based location. Outcome measures were collected in a university laboratory.

PATIENTS

Ten individuals with PD were randomly assigned to the Argentine tango (AT) group (n=5 [4 men]; mean age±standard deviation, 69.6±6.6 years) or the control group (n=5 [4 men]; mean age±standard deviation, 66±11.0 years).

INTERVENTIONS

The AT group participated in a community-based AT class for 1 hour twice weekly for 2 years. Control group participants were given no prescribed exercise. Blinded assessments occurred at baseline and 12 and 24 months.

OUTCOME MEASURES

Movement Disorder Society-Unified Parkinson Disease Rating Scale (MDS-UPDRS) III, Mini-Balance Evaluation Systems Test (Mini-BESTest), gait velocity (forward and backward), Timed Up and Go and dual-task Timed Up and Go, Six-Minute Walk Test (6MWT), MDS-UPDRS II, MDS-UPDRS I, and Freezing of Gait Questionnaire.

RESULTS

There were no differences between groups at baseline. A significant group-by-time interaction (F [2,8]=17.59; p<0.0001) was noted for the MDS-UPDRS III, with the AT group having lower scores at 12 and 24 months than the controls. Significant interactions were also noted for the Mini-BESTest, MDS-UPDRS II and I, and 6MWT.

CONCLUSION

This is believed to be one of the longest-duration studies to examine the effects of exercise on PD. Participation in community-based dance classes over 2 years was associated with improvements in motor and nonmotor symptom severity, performance on activities of daily living, and balance in a small group of people with PD. This is noteworthy given the progressive nature of PD and the fact that the control group declined on some outcome measures over 2 years.

Brain activity during complex imagined gait tasks in Parkinson disease

OBJECTIVE

Motor imagery during functional magnetic resonance imaging (fMRI) allows assessment of brain activity during tasks, like walking, that cannot be completed in an MRI scanner. We used gait imagery to assess the neural pathophysiology of locomotion in Parkinson disease (PD).

METHODS

Brain activity was measured in five locomotor regions (supplementary motor area (SMA), globus pallidus (GP), putamen, mesencephalic locomotor region, cerebellar locomotor region) during simple (forward) and complex (backward, turning) gait imagery. Brain activity was correlated to overground walking velocity.

RESULTS

Across tasks, PD exhibited reduced activity in the globus pallidus compared to controls. People with PD, but not controls, exhibited more activity in the SMA during imagined turning compared to forward or backward walking. In PD, walking speed was correlated to brain activity in several regions.

CONCLUSIONS

Altered SMA activity in PD during imagined turning may represent compensatory neural adaptations during complex gait. The lowered activity and positive correlation to locomotor function in GP suggests reduced activity in this region may relate to locomotor dysfunction.

SIGNIFICANCE

This study elucidates changes in neural activity during gait in PD, underscoring the importance of testing simple and complex tasks. Results support a positive relationship between activity in locomotor regions and walking ability.

Community-based Argentine tango dance program is associated with increased activity participation among individuals with Parkinson's disease

OBJECTIVE

To determine the effects of a 12-month community-based tango dance program on activity participation among individuals with Parkinson's disease (PD).

DESIGN

Randomized controlled trial with assessment at baseline, 3, 6, and 12 months.

SETTING

Intervention was administered in the community; assessments were completed in a university laboratory.

PARTICIPANTS

Volunteers with PD (n=62) enrolled in the study and were randomized to a treatment group; 10 participants did not receive the allocated intervention, and therefore the final analyzed sample included 52 participants.

INTERVENTIONS

Participants were randomly assigned to the tango group, which involved 12 months of twice-weekly Argentine tango dance classes, or to the no intervention control group (n=26 per group).

MAIN OUTCOME MEASURE

Current, new, and retained participation in instrumental, leisure, and social activities, as measured by the Activity Card Sort (with the dance activity removed).

RESULTS

Total current participation in the tango group was higher at 3, 6, and 12 months compared with baseline (Ps≤.008), while the control group did not change (Ps≥.11). Total activity retention (since onset of PD) in the tango group increased from 77% to 90% (P=.006) over the course of the study, whereas the control group remained around 80% (P=.60). These patterns were similar in the separate activity domains. The tango group gained a significant number of new social activities (P=.003), but the control group did not (P=.71).

CONCLUSIONS

Individuals with PD who participated in a community-based Argentine tango class reported increased participation in complex daily activities, recovery of activities lost since the onset of PD, and engagement in new activities. Incorporating dance into the clinical management of PD may benefit participation and subsequently quality of life for this population.

Balance impairment in individuals with Wolfram syndrome

AIM

Wolfram syndrome (WFS), a rare neurodegenerative disorder, is characterized by early onset insulin-dependent diabetes mellitus, optic atrophy, deafness, diabetes insipidus, and neurological abnormalities. Although previously unreported, we hypothesized that neurological complications may be detectable in relatively early stages of the disease. As the cerebellum and brainstem seem particularly vulnerable in WFS, we focused on balance functions critically dependent on these regions. The primary goal of this investigation was to compare balance in young individuals with WFS, in relatively early stages of the disease, to an age-matched cohort using a clinically applicable test.

METHOD

Balance was assessed via the mini-BESTest in 13 children, adolescents and young adults with WFS and 30 typically developing age-matched individuals.

RESULTS

A significant difference was observed between groups in balance as well as in three of four subcomponents of the mini-BESTest and in two timed tasks related to balance. Mini-BESTest scores were correlated with age among typically developing individuals. In the WFS group, mini-BESTest scores were related to overall motor dysfunction, but not age.

INTERPRETATION

Impairments in balance in WFS may occur earlier in the disease process than previously recognized and appear to be related to overall neurological progression rather than chronological age. Recognizing balance impairments and understanding which balance systems contribute to balance deficits in those with WFS may allow for development of effective patient-centered treatment paradigms.

Five times sit-to-stand test performance in Parkinson's disease

OBJECTIVES

To (1) determine intrarater and test-retest reliability of the Five times sit-to-stand test (FTSTS) in Parkinson's disease (PD), (2) characterize FTSTS performance in PD at different disease stages, (3) determine predictors of FTSTS performance in PD, and (4) determine the utility of the FTSTS for discriminating between fallers and nonfallers with PD, identifying an appropriate cutoff score to delineate between these groups.

DESIGN

Measurement study of community-dwelling individuals with idiopathic PD.

SETTING

A medical school laboratory.

PARTICIPANTS

Participants (N=82) were recruited via population-based sampling. The final sample included 80 participants. Two were excluded because of exclusion criteria and an unrelated illness, respectively.

INTERVENTIONS

Not applicable.

MAIN OUTCOME MEASURES

FTSTS time (seconds) was the primary outcome measure. Secondary outcome measures included the Mini-Balance Evaluation Systems Test (Mini-BEST), Maximal Voluntary Isometric Contraction-Quadriceps, 9-Hole Peg Test (9HPT), 6-minute walk, Freezing of Gait Questionnaire, Activities-Specific Balance Confidence Scale, Physical Activity Scale for the Elderly, Parkinson's Disease Questionnaire-39, and Movement Disorders Society-Unified Parkinson's Disease Rating Scale.

RESULTS

Interrater and test-retest reliability for the FTSTS were high (intraclass correlation coefficients: .99 and .76, respectively). Mean FTSTS performance was 20.25 ± 14.12 seconds. All mobility measures were significantly correlated with FTSTS (P<.01). The Mini-BEST and 9HPT together explained 53% of the variance in FTSTS. Receiver operating characteristic analysis determined a cutoff of 16.0 seconds (sensitivity, .75; specificity, .68) for discriminating between fallers and nonfallers, with an area under the curve of .77.

CONCLUSIONS

The FTSTS is a quick, easily administered measure that is useful for gross determination of fall risk in individuals with PD.

Randomized controlled trial of community-based dancing to modify disease progression in Parkinson disease

BACKGROUND

Tango dancing has been effective in improving measures of physical function in people with Parkinson disease (PD). However, all previous studies were institution-based, tested participants on medication, and employed short-term interventions.

OBJECTIVE

To determine the effects of a 12-month community-based tango program for individuals with PD on disease severity and physical function.

METHODS

Sixty-two participants were randomly assigned to a twice weekly, community-based Argentine Tango program or a Control group (no intervention). Participants were assessed off anti-Parkinson medication at baseline, 3, 6, and 12 months. The primary outcome measure was the Movement Disorders Society-Unified Parkinson Disease Rating Scale 3 (MDS-UPDRS-3). Secondary outcome measures were the MDS-UPDRS-1, MDS-UPDRS-2, MiniBESTest balance test; Freezing of Gait Questionnaire (FOG_Q); 6-Minute Walk Test (6MWT); gait velocity for comfortable forward, fast as possible forward, dual task, and backward walking; and Nine-Hole Peg Test (9HPT).

RESULTS

Groups were not different at baseline. Overall, the Tango group improved whereas the Control group showed little change on most measures. For the MDS-UPDRS-3, there was no significant change in the Control group from baseline to 12 months, whereas the Tango group had a reduction of 28.7% (12.8 points). There were significant group by time interactions for MDS-UPDRS-3, MiniBESTest, FOG_Q, 6MWT, forward and dual task walking velocities, and 9HPT in favor of the dance group.

CONCLUSIONS

Improvements in the Tango group were apparent off medication, suggesting that long-term participation in tango may modify progression of disability in PD.

Measuring participation in individuals with Parkinson disease: relationships with disease severity, quality of life, and mobility

PURPOSE

Our aims were to: (1) describe participation in people with Parkinson disease (PD), (2) evaluate the relationship between quality of life and participation and (3) determine the mobility measures which are predictive of participation.

METHODS

Participants with idiopathic PD (n = 62) were tested off medication for participation (Activity Card Sort), quality of life (PDQ-39), disease severity (MDS-UPDRS) and mobility (Berg Balance Scale, Five Time Sit to Stand (FTSTS), Six Minute Walk, forward walking velocity, dual-task walking velocity and Freezing of Gait Questionnaire (FOGQ)). Relationships of all variables to participation were examined using Pearson correlations. Subsequent regression analysis was employed to determine the mobility measures which best predicted the participation.

RESULTS

Participants with PD retained, on average, 78.3% (SD = 15.6%) of total activities. Participation was negatively correlated with all PDQ-39 domains (r range -0.36 to -0.78, all p < 0.005) with the mobility domain having the strongest correlation. All mobility measures were significantly correlated with participation, with the final regression model including only FTSTS and FOGQ which combined explained 37% of the variance in participation.

CONCLUSIONS

Participation is highly related to mobility-related QOL and may be most impacted by ability to stand up from a chair and freezing of gait in those with PD.

Propagule size and the relative success of exotic ungulate and bird introductions to New Zealand

We investigated factors affecting the success of 14 species of ungulates introduced to New Zealand around 1851-1926. The 11 successful species had a shorter maximum life span and were introduced in greater numbers than the three unsuccessful species. Because introduction effort was confounded with other life-history traits, we examined whether independent introductions of the same species were more likely to succeed when a greater number of individuals were introduced. For the six species with introductions that both succeeded and failed, successful introductions always involved an equal or greater number of individuals than unsuccessful introductions of the same species. For all independent introductions, there was a highly significant relationship between the number of individuals introduced and introduction success. When data for ungulate and bird introductions to New Zealand were combined, a variable categorizing species as ungulate or bird was a highly significant predictor of introduction success, after variation in introduction effort was controlled. For a given number of individuals introduced, ungulates were much more likely to succeed than birds.

Expression and function of the ghrelin axis, including a novel preproghrelin isoform, in human breast cancer tissues and cell lines

While oestrogen, progesterone and growth factors, including growth hormone (GH), are clearly implicated in the pathogenesis of breast cancer, there is now evidence that the newly described ghrelin axis is also involved. The aims of this study were to investigate the expression of the ghrelin axis in breast cancer tissues and cell lines and to examine the effect of ghrelin on breast cancer cell proliferation in vitro. Ghrelin and its functional receptor, the growth hormone secretagogue receptor (GHSR) type 1a, were expressed in normal breast tissue and breast cancer specimens and cell lines. In contrast, the truncated GHSR type 1b isoform was exclusively expressed in breast carcinoma, suggesting that it has potential as a diagnostic marker. Ghrelin treatment significantly increases the proliferation of the MDA-MB-435 and MDA-MB-231 breast cancer cell lines in vitro. In addition, we have described the expression of a human preproghrelin isoform, exon 3-deleted preproghrelin, which encodes mature ghrelin plus a novel C-terminal peptide. Quantitative RT-PCR was used to demonstrate that this mRNA isoform is highly expressed in the MDA-MB-435 metastatic breast cancer cell line relative to the benign MCF-10A breast epithelial cell line. The unique C-terminal peptide of exon 3-deleted preproghrelin is expressed in the glandular epithelium of breast cancer tissues, with high-grade carcinoma exhibiting the strongest immunoreactivity. The data presented here suggest that components of the ghrelin axis may represent novel markers for breast cancer and potential therapeutic targets.

Expression of the ghrelin axis in the mouse: an exon 4-deleted mouse proghrelin variant encodes a novel C terminal peptide

Ghrelin, an n-octanoylated 28-amino-acid peptide capable of inducing GH secretion and food intake in humans and rats, is the endogenous ligand for the GH secretagogue receptor (GHS-R). Here we describe the expression and tissue distribution of the ghrelin/GHS-R axis in the mouse. We also report for the first time the identification of a novel mouse ghrelin mRNA variant in which there is a complete deletion of exon 4. Translation of this variant mRNA yields a protein containing ghrelin and an alternative C-terminal domain with a unique C-terminal peptide sequence. RT-PCR with primers specific for mouse ghrelin was used to demonstrate the mRNA expression of the full preproghrelin transcript and the exon 4-deleted variant in multiple mouse tissues. Real-time PCR was also employed to quantitate mRNA expression of ghrelin, the novel isoform and a previously reported ghrelin gene variant, ghrelin gene-derived transcript. We also demonstrated the tissue expression of the functional GHS-R in the mouse. Immunohistochemistry, employing antibodies raised against the mature human n-octanoylated ghrelin peptide and the putative C-terminal peptide encoded by the exon 4-deleted proghrelin variant, was used to demonstrate protein expression of ghrelin and the variant in multiple mouse tissues including stomach, kidney, and reproductive tissues. The coexpression of ghrelin and its receptor in a wide range of murine tissues suggests varied autocrine/paracrine roles for these peptides. Exon 4-deleted proghrelin, a novel mouse proghrelin isoform with a unique C-terminal peptide sequence, is also widely expressed in the mouse and thus may possess biological activity in these tissues.

Tooth loss occurring at a place other than a health-care facility: 72-month incidence

Dental care can occur within or outside the formal health-care system. We hypothesized that certain subject characteristics would partly explain one type of dental self-care, non-professional extractions. A representative sample of diverse groups of dentate adults was studied. In-person interviews and clinical examinations were conducted at baseline, 24, 48, and 72 months, with semi-annual telephone interviews in between. Of 699 participants, 291 (42%) reported loss of at least one tooth, of whom 42 (14% of those with tooth loss) reported having lost the tooth at a place other than a health-care facility. Ninety-four percent of non-professionally lost teeth were self-extracted; relatives extracted the remainder. Fifty-eight percent of these teeth were deliberately removed; the remainder came out while subjects were eating or brushing their teeth, or due to injury. Attachment loss and mobility at previous examination were consistent with the occurrence of non-professional extraction. The incidence magnitude was substantive and persistent throughout follow-up.

Determinants of establishment success in introduced birds

A major component of human-induced global change is the deliberate or accidental translocation of species from their native ranges to alien environments, where they may cause substantial environmental and economic damage. Thus we need to understand why some introductions succeed while others fail. Successful introductions tend to be concentrated in certain regions, especially islands and the temperate zone, suggesting that species-rich mainland and tropical locations are harder to invade because of greater biotic resistance. However, this pattern could also reflect variation in the suitability of the abiotic environment at introduction locations for the species introduced, coupled with known confounding effects of nonrandom selection of species and locations for introduction. Here, we test these alternative hypotheses using a global data set of historical bird introductions, employing a statistical framework that accounts for differences among species and regions in terms of introduction success. By removing these confounding effects, we show that the pattern of avian introduction success is not consistent with the biotic resistance hypothesis. Instead, success depends on the suitability of the abiotic environment for the exotic species at the introduction site.

Coping with tooth pain: a qualitative study of lay management strategies and professional consultation

This research analyzes transcripts of semi-structured interviews with patients presenting with tooth pain at a rural dental clinic in North Florida. The primary objectives are to identify the strategies patients use to manage their pain and to elucidate the decision-making process leading to the clinic visit. Although respondents understood that their condition was not self-limiting, only about one-half contacted the clinic within several days of the onset of their pain. Most tried one or more lay management strategies.

Risk indicators of edentulism, partial tooth loss and prosthetic status among black and white middle-aged and older adults

OBJECTIVES

To describe the prevalence and risk indicators of edentulism; to describe the frequencies of wearing removable dentures; to describe the prevalence and risk indicators of fixed prosthetic restorations; to test the hypothesis that fixed prosthetic restorations are most likely to have been placed in persons at lower risk for dental and periodontal diseases, and to test the hypothesis that, with dental disease, dental behaviors, dental attitudes and ability to afford crowns taken into account, blacks are less likely than whites to have received crowns.

METHODS

The Florida Dental Care Study is a cohort study of subjects 45 years old or older. A telephone screening interview was done as a first stage to identify 5254 subjects who met eligibility requirements and who self-reported whether they were edentulous. In a second stage, a subsample of dentate subjects was contacted after they completed their telephone screening interview. Of these, 873 subjects completed a baseline in-person interview and dental examination.

RESULTS

A total of 19% of first-stage subjects were edentulous. In a single multiple logistic regression, having a poorer self-rated level of general health was significantly associated with edentulism, as were being poor, older and white. Among the second-stage participants (all of whom were dentate), several prosthetic patterns were observed. For example, a total of 64% of maxillary full denture wearers reported wearing their denture all the time. Participants had also received numerous fixed prosthodontic services. The proportion of subjects with at least one crown varied widely by subject characteristics.

CONCLUSIONS

A substantial percentage of non-ideal frequencies of wearing removable prostheses was reported, as were prosthesis-related soreness and broken prostheses. Although we expected and observed an association between having a fixed prosthetic crown and periodontal status, dental fillings, dental attitudes and financial resources, a residual association with race suggests that blacks are much less likely to receive prosthetic crowns. The several possible reasons for this circumstance warrant further investigation.

Twenty-four month incidence of root caries among a diverse group of adults

OBJECTIVES

(1) Describe for a diverse sample the 24-month incidence of root caries, and (2) test its association with a broad range of clinical, behavioral, financial, and sociodemographic factors.

METHODS

The Florida Dental Care Study was a cohort study of randomly selected subjects who had at least 1 tooth and were 45 years or older at baseline. In-person interviews and clinical examinations were conducted at baseline and 24 months, with 6-monthly telephone interviews between those times; 723 subjects participated for both examinations. A multinomial logistic regression was done to predict whether the subject was in one of four mutually exclusive groups [new root decay only (NDO); new root filling(s) only (NFO); both new decay and new filling(s) (BOTH), or had neither (NONE)].

RESULTS

Thirty-six percent of subjects had at least 1 new root decayed and/or filled surface (DFS); 17% were in the NDO group, 14% in the NFO group, and 5% in the BOTH group. When limited to participants who had a nonzero increment, the mean (SD) DFS was 2.7 (2.9). Baseline clinical condition (presence of root decay, root filling(s), coronal decay, noncarious root defects, number of teeth present, percent of teeth with at least 4 mm of attachment loss) was predictive of moving from the NONE group into the NDO, NFO, or BOTH groups. The addition of behavioral, financial, and sociodemographic factors improved model fit. For example, regular dental attenders were significantly more likely to move from the NONE group into the NFO group, but regular attendance was not associated with a lower probability of moving from the NONE group into the NDO or BOTH groups.

CONCLUSIONS

Root caries is a substantive dental health problem in this diverse sample of adults. These analyses demonstrate the utility of disaggregating caries incidence into four mutually exclusive groups for predictive models.

Twenty-four month coronal caries incidence: the role of dental care and race

OBJECTIVES

To describe for a diverse sample of dentate middle-aged and older adults: (1) the 24-month incidence of coronal caries, and (2) its association with a broad range of clinical, behavioral, financial, attitudinal, and sociodemographic factors.

METHODS

The Florida Dental Care Study is a prospective observational longitudinal cohort study of 873 persons who at baseline had at least 1 tooth and were 45 years or older. In-person interviews and clinical examinations were conducted at baseline and 24 months, with 6-monthly telephone interviews between those times. A multinomial logistic regression was done to predict whether a participant was in one of four mutually exclusive groups at the 24-month examination (new decay only [NDO]; new filling(s) only [NFO]; both new decay and filling(s) [BOTH]; or neither [NONE]).

RESULTS

Only 33% of the 24-month participants were in the NONE group. There was no significant difference in caries incidence between regular attenders and problem-oriented attenders, regardless of whether teeth crowned at baseline, incident crowns, or incident root fragments were excluded. However, once differences in incident tooth loss and baseline clinical, behavioral, financial, and attitudinal differences were taken into account, regular attenders did appear to benefit by developing fewer coronal lesions and fewer dental symptoms than problem-oriented attenders. Baseline carious surfaces, filled surfaces, number of teeth, and bulk restoration fractures predicted caries incidence, but baseline cusp fractures did not. Persons with negative dental attitudes were more likely to be in the NDO and BOTH groups, and negative attitude toward brushing and flossing (but not their frequency) also predicted caries incidence.

CONCLUSION

Certain baseline clinical conditions, approach to dental care, ability to pay for dental care, dental attitudes, race, and age group were predictive of coronal caries incidence, and regular attenders appeared to benefit from regular attendance.

Dental self-care among dentate adults: contrasting problem-oriented dental attenders and regular dental attenders

Self-care behaviors are common and can act as substitutes for or supplements to formal health care services. We tested the hypothesis that problem-oriented dental attenders (POAs) report more dental self-care behaviors than do regular dental attenders (RAs), presumably as a substitute for professional care. The Florida Dental Care Study is a longitudinal cohort study of changes in oral health, in which we measured dental self-care behaviors related to three common dental problems: toothache pain, bleeding gums, and tooth loss. Despite using less dental care, POAs were less likely to report "conventional" methods as means to prevent the three dental problems; however, they were more likely to report that homemade remedies, topical medications, or mouthwashes were ways to prevent or treat these problems. POAs were also more likely to believe that "nothing can be done" to prevent these problems. Additionally, POAs had more negative dental attitudes, used less dental care during follow-up, had more dental disease, were the only persons who extracted at least one of their own teeth, and were more likely to use tobacco. With the exception of dental self-extractions, no single self-care belief or behavior distinguished POAs from RAs, nor were POAs likely to have different explanations for dental problems. Instead, the pattern was one of modest differences on a number of items. Although POAs use less dental care, they do not compensate by employing more "conventional" dental self-care behaviors, but report being more likely to employ "unconventional" behaviors. They also are more likely to believe that nothing can be done to prevent dental problems.

Patterns of change in self-reported oral health among dentate adults

BACKGROUND

Although self-assessments of oral health have become useful tools in dental research, the use of self-reports to study changes in oral health over time has been limited. The aim of this investigation was to describe how oral disease and tissue damage, pain, functional limitation, disadvantage, and self-rated oral health change over time.

METHODS

The Florida Dental Care Study (FDCS) (n = 873) is a longitudinal study of oral health among dentate adults (age, > or = 45 years). Incidence rates and transition probabilities were used to describe changes in oral health over a 24-month period.

RESULTS

The probability of reporting a specific problem during the 24-month study ranged from 0.52 for perceived need for dental care to 0.07 for avoided eating with others. Only dental sensitivity and perceived need for dental care had transition probabilities >0.20. Decomposition of transition probabilities revealed moderate probabilities of onset coupled with relatively high probabilities of recovery.

CONCLUSION

Although oral health status is clearly dynamic, no individual measure exhibited profound fluctuation. Most oral health problems were episodic rather than chronic. Patterns of change in oral health varied across dimensional lines.

Tooth-specific and person-level predictors of 24-month tooth loss among older adults

OBJECTIVES

To describe: (1) the 24-month incidence of tooth loss in a diverse sample of dentate adults; and (2) the clinical, attitudinal, behavioral, and sociodemographic correlates of tooth loss incidence.

METHODS

The Florida Dental Care Study is a prospective longitudinal cohort study of persons who at baseline had at least one tooth, were 45 years or older, and who resided in north Florida. An in-person interview and clinical examination were conducted at baseline and 24-months after baseline, with 6-monthly telephone interviews between those times. A two-level hierarchical generalized linear regression (logit model) was used to quantify tooth-specific and person-level factors simultaneously.

RESULTS

Of the 739 persons who attended for a 24-month examination, 24% lost one or more teeth during follow-up. Tooth loss was more common in persons with dental disease at baseline, incident dental signs or symptoms, those with negative attitudes toward dental care and dental health, those with limited financial resources, older adults, blacks, females, and problem-oriented users of dental care (as distinct from regular attenders). Although disease presence at baseline was a major factor associated with incident tooth loss, most diseased teeth were in fact still present 24 months after baseline.

CONCLUSIONS

Other than periodontal attachment loss, severe tooth mobility, and dental caries, no single factor was a dominant predictor of tooth loss; instead, numerous factors made statistically significant but small contributions to variation in tooth loss. Tooth loss apparently is the result of complex interactions among dental disease, incident dental signs and symptoms, tendency to use dental care in response to specific dental problems, dental attitudes, and ability to afford non-extraction treatment alternatives.

Rural health networks in Florida

This article describes the development of rural health networks in Florida, which has adopted formal policies to support these networks. First, the history and content of the relevant legislation are described. The current networks are identified and their development to date summarized. Finally, a detailed case study is employed to outline the steps taken to establish one network.

Changes in health insurance coverage within rural and urban environments--1977 to 1987

This study examines changes in the health insurance coverage of the nonelderly population in rural and urban areas between 1977 and 1987, using data from the National Medical Care Expenditure Survey (NMCES) and the National Medical Expenditure Survey (NMES). It was designed to test the hypothesis that differences in the rates of health insurance coverage in rural and urban areas have diminished over time, and to explore the composition of changes in coverage within rural and urban environments. The data suggest that the proportions of the populations that are without health insurance in rural and urban areas have converged since 1977. Although both rural and urban settings witnessed increases in the proportion of their populations without health insurance from any source, urban regions experienced a greater increase than did rural areas. These changes occurred among most subgroups within the population. In no subgroup did the percentage of the population without insurance in urban areas exceed that found in rural areas in either 1977 or 1987.

Rural-urban comparisons of age and health at the time of nursing home admission

This study re-examines the contention that rural elders admitted to nursing homes are younger and healthier than their counterparts who enter urban facilities. The analysis uses interview data gathered in both urban and rural nursing homes. Residents were interviewed at or near the time of admission regarding their health and circumstances immediately prior to entering the nursing home. The findings indicate few and modest differences between urban and rural residents. In those instances where differences are observed, there is ambiguity--some measures indicate lower health status in the case of rural residents, while others suggest that urban residents are more likely to report health impairments. The divergence of these findings from earlier research may be due to differences in the study populations, measurement differences, or, more likely, that policies and processes have changed over time.

Taking dental self-care to the extreme: 24-month incidence of dental self-extractions in the Florida Dental Care Study

OBJECTIVE

A common response to health-related symptoms is to treat oneself in lieu of or prior to seeking formal health care. Among the more extreme forms of dental self-care is dental self-extraction. To our knowledge, no study of the incidence of this behavior has been conducted. The objective of this study was to determine if one form of dental self-care, dental self-extraction, is a real phenomenon, and if so, to determine its incidence.

METHODS

The Florida Dental Care Study is a longitudinal study of changes in oral health, whose subjects participated for an interview and clinical examination at baseline and 24 months after baseline.

RESULTS

Of the 739 persons who participated through 24 months 176 lost one or more teeth. Of these 176 persons, 13 (7%) extracted one or more of their own teeth. The clinical status at baseline of the self-extracted teeth was consistent with the ability to self-extract.

CONCLUSION

The phenomenon of dental self-extraction is real and is not limited to residents of developing nations or geographically isolated areas. Because of the potential for prolonged bleeding or bacterial endocarditis in certain population groups, community health clinicians and officials should be cognizant of this behavior.